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alaaca ndnf nr hma -fFnffn dasioned for use on elite (12 -pitch) lvoewriter.) <br />Form Approved. OMB No, 2050-0039 <br />A Form 8700-22 (Rev. 3-05) Prevlous edition are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Pee 1 of <br />3. Emergency Response Phone <br />i;-filb `7,i <br />4. Manifest Trackln Number . <br />320 JJK <br />WASTE MANIFEST <br />.at�i0ra <br />1 <br />5. Generators Name and Mailing Address Generators Site Address (if different than malling address) <br />wRmci t F•» fit �F?i : r�t'_tCdS C. tl� t : Jc.4„ _Yr . <br />9TX;KTWI, CA. 9:5Z19 <br />Generator's PhorWjr_o • 7 <br />6, Transporter 1 Company Name U.S. EPA ID Number <br />iW,4&ll is Ell Sf. 'zNTAL gff"—TES INC. 4nfK�i fi ti <br />T. Transporter Company Name U.S. EPA ID Number <br />B, Designated Facility Name and Site Address U.S. EPA ID Number <br />F:g�A�`;r �TvIP,�S�fA,IEtiI'F�+1 'SE'E?`,�CE? r tutu: <br />I$19ftt�+1,'Eir �C'F]. Ci?tiel?s55 <br />V4EST Sr1C34,+1NW14-fs3. CP $ <br />Facility's Phone06--%: 1-V4-11 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />tO. Containers <br />11. lbtd -' <br />f2, Unit <br />13 Weeta CodN ' <br />No. <br />Type <br />HM <br />and Packing Group (H any)) <br />Quantity <br />Wt.lVol. <br />1. 4i : { CPA h1AZ, +31j3 Y4ia.ST at1 iD tit„ Lem t;? <br />00t <br />Dull <br />40C <br />t9 <br />.. <br />3. <br />4 <br />% Special Handling instructions and Additional Information f <br />t1.4AVLEIR.'7 -3WULD 8E` TR`PAM AM IJP >~.P9RC1':tD F'S -'E <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classliled, packagedk ac'f <br />marked and labeledlplacarded, and are In all respects In proper condition for transport according to applicable Intemational and national governmental regulations. If export shipment and l am the Primary' <br />Exporter, I certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified In 40 CFR 262.27(a) rf I am a large quantity generator) or (b) (if] am a small quantity generator) Is he, <br />.GeneratoeslOfferoris PrintedfTyped Name Signature Month Day • <br />:... <br />- <br />F <br />matShipments - - - <br />1H. Inte ional <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexit <br />Z <br />. TFansporter signature (for exports only): Date leaving U.S.: <br />17. TransporterAdmowledgment of Receipt of Matedals <br />co <br />d ant�lt+ Day Year.' <br />efTypgmei <br />Transporter 1 Printd <br />`` a, <br />'''moi <br />:CL. <br />_ <br />C i� _ 1 , <br />Z <br />.Transporter 2 Printed/Typed Name 115i0fature Monlh Day Year <br />F-' <br />18. Discrepancy <br />' <br />f --f <br />18a. Discrepancy Indication Spacoquantity Type ❑ Residue ❑ Partial Rejection LJ FuO.ReJectlon' <br />Manifest Reference Number. <br />18b. Alternate Fad ty (or Generator) U.S. EPA ID Number <br />J <br />� <br />V <br />III, <br />FacIRWs Phone: <br />� <br />18c. Signature ofAdtemate Facility (or Generator) Month Day' ' Year <br />49. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br />Q. <br />1 <br />2 <br />3• <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pdntedfiyped Name Signature Month Dey <br />A Form 8700-22 (Rev. 3-05) Prevlous edition are obsolete. GENERATOR'S INITIAL COPY <br />